Healthcare Provider Details

I. General information

NPI: 1932637923
Provider Name (Legal Business Name): MEREDITH EALISE BOURQUE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2017
Last Update Date: 06/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 DUNCAN DR
PROVIDENCE RI
02906-7003
US

IV. Provider business mailing address

530 N MAIN ST
PROVIDENCE RI
02904-5762
US

V. Phone/Fax

Practice location:
  • Phone: 401-383-5150
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number56383
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN56383
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: